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1

What is the goal of cardiac assessment What is the cardiac evaluation alogrithm?

The goal of preop cardiac assessment is to: identify patients with heart disease who are at high risk for perioperative cardiac morbidity or mortality or those with modifiable conditions or risk.

  • Step 1: urgency of surgery
  • Step 2: determine if active cardiac condition nStep 3: determine surgical risk
  • Step 4: assess functional capacity
  • Step 5: assess clinical predictors/markers
  • We use American college of cardiology and American heart association

2

What determine urgency of surgery (step 1)?

  • one where life or limb would be threatened if surgery did not proceed:
    • emergent- within < 6 hours
    • urgent- within 6-24 hours
      • Emergency sx → focus on:
        • Risk reduction- ex: BB, statins, pain management
        • perioperative surveillance – ex: serial EKG, cardiac enzymes

3

What is Step 2 in Cardiac eval algorithm?

  • Active cardiac conditions should be ruled out in pt not requiring emergent sx
  • example: TREAT or DELAY/CANCEL if active conditions (unless emergency sx)
    • Acute coronary syndrome
    • decompensated heart failure
    • severe valvular disease
    • pulm HTN
    • significant arrhythmias
      • Should be ruled out in patients not requiring emergency surgery.
      • If any conditions present → TREAT
  • Recent MI— Attempt to find DATE of infarction
    • Nonurgent surgerydelay for 60 days.<< american heart guidlines

4

What is the risks of perioperative MI?

  • Risk of perioperative MI in the patient with previous MI
    • General population= 0.3%
    • MI > 6 months =6%
    • MI if 3-6 months = 15%
    • MI< 3months =30%

5

What is Step 3 in cardiac algorithm?

  • perioperative cardiac risks for non cardiac surgical procedures
    • CV risk under what type of sx undergoing
  • Highest risk involving aorta/vascular sx
  • Low risk- cataract, breast, ambulatory sx
    • LOW RISK→ proceed directly to sx 
    • KNOW TABLE

6

What is step 4 in cardiac algorithm?

Determine METS

  • METs (Metabolic equivalent of Task)= Exercise equivalent
  • 1 MET= amount of O2 consumed while sitting at rest
    • O2 consumption of 3.5 ml/min/kg body wt
  • Preop- fx capacity should be found
    • AHA:
      • > 4 METs = proceed directly to sx
        • “Are you able to walk a flight of stairs?” → YES = immediately know they are MET=5
      • < 4 METs = undergo CV stress testing prior to going to elective sx

7

What is the Duke Activity Specific Index (DASI)?

Estimated METS = (0.43 X DASI score) + 9.6 

                                                   3.5

  • Asking pt not necessarly estimate exercise capacity
  • Not seen used… but more reliable estimate of exercise capacity
  • Don’t need to know formula for test…

8

What can you use in lieu of assessing functional capacity?

  • Canadian Cardiac Guidelines recommend utilization of Cardiac biomarkers (BNP, Pro-BNP) to assess periop risk
    • Low risk:
      • BNP: < 100
      • Pro-BNP: < 300
    • High risk:
      • BNP: > 300
      • Pro-BNP: > 900

9

What are some general risk factors for periop cardiac morbidity/mortality for non cardiac sx

General risk factors: INCREASED periop cardiac m/m (know!!!)

  • High risk surgeries
    • ex: Aortic and other vascular sx
    • Peripheral vascular sx
  • Ischemic heart ds hx
    • unstable angina – GREATEST risk of periop MI
  • CHF hx
  • Cerebrovascular ds hx
  • Diabetes
  • Serum creatinine > 2 mg/dL

10

What is  Step 5 in cardiac evaluation algorithm? What are minor risk factors for CAD?

  • Clinical risk factors for CAD
  • # of CV clinical predictors (ex: IHD, HF, CVA, DM, Renal insufficiency) → determine the likely benefit of further cardiac testing who reach step 5
    • Pts with no clinical predictors → proceed to sx
    • With risk predictors → benefit from further testing, only if results will alter management

     MINOR : clinical markers for CAD

  • HTN
  • abnormal ECG
  • smoking
  • increased age/ male sex –hypercholesterolemia
  • rhythm other than sinus rhythm –family history
  • obesity
    • COLLECTIVELY: Recognized markers for Heart Disease
    • INDEPENDENTLY: do NOT show increase periop CV risk

11

Intermediate clniical predictors for periop CV M/M?

  • known CAD
  • Prior MI > 1 month and Q waves on ECG
  • history of mild, stable angina
  • compensated or previous LV failure / CHF
  • Diabetes
  • chronic renal insufficiency (Cr > 2.0 mg/dL)
  • cerebrovascular disease (stroke, TIA)

12

Major clinical predictors of increased CV risk?

Major (ACTIVE cardiac conditions- from step 2) – of periop CV M/M risk

  • unstable coronary syndromes
  • acute or recent MI < 1 month
  • unstable or severe angina
  • decompensated CHF
  • significant arrhythmias 3rd degree, SVT, uncontr AF
  • severe valvular disease

13

What is the Cardiac Risk Index?

  • High-risk sx
  • Ischemic Heart dx
  • CHF hx
  • CV dx hx
  • Cerebral vascular dx
  • DM requiring insulin
  • Creatinine > 2.0 mg/dl
    • Summation provide score to estimate risk of major CV events
      • Ex: Score 0 = 0.4% risk of major CV event periop
      • >3= 5.4% risk of major CV event periop

14

Basic components of cardiac exam?

  • History taking
    • –including medications
  • Physical exam
  • Resting 12-Lead ECG
    • if indicated → within 30 days of surgery

15

What is important to assess for on EKGs preop?

  • EKGs →
    • assessment of rhythm
    • L ventricular hypertrophy
    • Prior MI (abnormal Q-waves).
      •  Ex: Abnormal Q-waves in high risk patients = highly suggestive of previous MI
      • Absent Q-wave does not rule out MI in past
  • It has been estimated that ~30% of MIs occur without symptoms
    • “silent infarct”→ can only be detected on screening EKG
      • Silent infarcts occurrence most:
        • Diabetic patients
        • Hypertensive patients
  • However, the 2014 ACC/AHA guidelines recommend a preop 12- lead EKG only for patients w known CAD or other structural heart ds.

16

What are the recommendations for preop 12- lead EKG?

Class IIA? IIB? III?

  • CLASS IIA RECOMMENDATION:
    • It is Reasonable to Perform the Procedure (12-lead) for patients with:
      • IHD
      • significant arrhythmia
      • PAD
      • CVD
      • significant structural heart disease
        • EXCEPT: if undergoing low-risk surgical procedures (ex: breast, cateract, ambulatory, superficial, endoscopic sx)
  • Class IIB:
    • The Procedure may be Considered for asymptomatic pts w/o known coronary heart ds, except for those undergoing low-risk surgical procedures
  • Class III:
    • The Procedure Should Not Be Performed Because it is Not Helpful for asymptomatic patients undergoing low-risk surgical procedures

17

What are some adjunct tests done to patient with CV risk factors or pt undergoing high risk sx?

  • Chest X-Ray
  • Labs
  • Stress testing
  • Echocardiography
  • MRI
  • CAT scan
  • Coronary angiography
    • (Gold Standard-for coronary anatomy)
      • Rule of thumb: Will results of test change management of pt?
        • YES → proceed with test collection

18

What is goal of history?

  • Goal of history is to elicit:
    • Severity
    • Progression
    • functional limitations
      • Interviewing: Identify RISK factors (not symptoms)
        • Symptoms vary person to person
          • Ex: Elderly, females, DM – present with atypical features
          • Women MI s/s: N/V, SOB, back pain (atypical features)

19

What are some questions that can be asked during cardiac evaluation?

  • Short of breath lying flat (orthopnea)?
  • Paroxysmal nocturnal dyspnea?
  • Congestive heart failure?
  • Heart attack? (diagnosed by EKG or elevated enzymes)
  • Angina (with activity/ @ rest), or chest pain/ pressure/ tightness related to your heart?
    • What are precipitating factors?
    • Associated symptoms?
    • What is frequency?
    • Duration of pain?
    • Methods of relief?
  • Irregular heartbeat or palpitations?
  • Pacemaker? ICD?
  • Heart murmur?
  • Diagnostic tests, therapies, names of treating physician?
  • Problems with blood pressure or HTN?
    • Untreated HTN ptsgreatest ¯in BP during induction
      • ­ risk of myocardial ischemia/arrythmias  
  • PVD?
  • TIA/CVA?

20

What is paroxysmal nocturanl dyspnea?

  • Sudden difficulty breathing and orthopnea that awakens pts from sleep 
    • Prompts pts to sit up, stand up, go to window for air
    • +/- wheezing
    • ~1-2 hrs after bed- occurs around same time on subsequent nights
      • → Indicative: LV HF, Mitral Stenosis, or Obstructive Lung Dx

21

Even more questions to ask....

  • Diabetes?
  • Renal insufficiency?
  • High cholesterol?
  • Estrogen status?
    • Research: Estrogen offers CV protection
  • Age and weight?
  • Fatigued?
  • Syncope?
  • Anemia?
  • Smoke or drink alcohol?
    Illicit drug use?
    • Marijuana→ tachycardia
    • Opioids → hypotension & bradycardia
    • Cocaine → tachycardia & HTN

22

What is angina?

  • Angina – sign of imbalance between myocardial oxygen supply vs. demand.
    • GERD and Esophageal spasm MIMIC angina
      • heartburn can result in angina-like pain
      • Can be relieved by Nitroglycerin
  • Stable vs unstable angina

23

What is stable angina?

  • Stable—substernal discomfort à exertion. 
    • Relieved by: rest, NTG, or both in < 15 min.
    • Typical pattern à radiation to jaw, shoulder, neck, inner aspect of arm.
      • Poses no greater threat to periop MI than the absence of anginal symptoms

24

What is unstable angina?

  • Unstable—occurs at rest
    • newly developed (w/in past 2 mo) or angina that last > 30 min. 
    • Angina that has worsened w/ inc freq, intensity, or duration.
    • Less responsive to meds.
    • A/w highest risk for perioperative MI
    • Present in EKG, not labs:
      • Produces transient ST or T wave changes WITHOUT development of Q waves
      • No elevation of cardiac enzymes
  • Unstable angina--> cancel elective sx until evaluated
    • WORKUP: coronary angiography, exercise EKG stress testing

25

What is Prinzmetal's Angina?

  • aka variant angina
  • Produced by Coronary vasospasm (rather than occlusion)
  • Vasospastic angina that occurs at rest.
    • Triggered by stress, cold weather, smoking, medications, etc
  • Presentation:
    • ST elevation during episode on 12-lead
    • patients have a higher incidence of migraine HA and Raynaud’s (perhaps due to a basic vaso-spastic disease)
  • Treatment: Nitrates, CCBs

26

What are some things we want to know about patient with pacemake and ICD?

Things to know:

  • The indication for insertion of the pacemaker or ICD
    • Ask why?
  • The underlying rhythm and rate
    • Do you know what number
  • The type of pacemaker (demand, fixed), the chamber paced, and the chamber sensed
    • Does your heart ever beat on its own? Or are you completely dependent on it?
  • Have the pacemaker or defibrillator interrogated by a qualified member of CIED
    • Note current settings and battery life
  • Evaluate effect of magnet
  • Inactivate ICD tachyarrhythmia detection and put defibrillator pads on

27

When should pacemaker/ICD be evaluated before sx?

  • Device should be evaluated before surgery
    • Pacemakers: Assess w/in 12 mo of elective sx
    • ICD: assess w/in 6 mo of elective sx
      • Ex: Pacemaker evaluation → card that has date of insertion, manufacturer, contact rep
      • Hospital contacts major company reps in area. Always available and can answer questions. Assist with pre/intra/post op 

28

Periop consideration of pacemakers and ICDs? What should be done to ICDs intraop? Pacemakers? Special considerations?

  • Electromagnetic interference can occur with electrocautery, which can inhibit pacemaker firing
    • Ex: Demand pacemakers sense electrocautery→ inhibit pacemaker firing → ASYSTOLE
  • ICD devices → should have tachyarrythmia treatment algorithms program turned off before sx and on after sx
    • Prevent unwanted shocks that signals might interpret as V tach or V fib
    • ICD always have pacemaker fx → place in asynchronous mode
  • Ensure monitor enabled to displace pacer spikes **
  • Have a magnet immediately available. 
    • Most pacemakers can be converted to a fixed rate (asynchronous mode) by placing a magnet over the pacemaker box
    • Demand pacemakers Intraop:
      • Program Asynchronous mode
      • Place magnet over device – converts to fixed rate (90-100 bpm)
        • Ensure when magnet removal → automatically resets when removed (pacemaker rep helps)
  • Grounding pads should be as far from the pulse generator and leads as possible
  • Bipolar electrocautery is preferred; avoid monopolar
  • Monitor some form of blood flow (pulse oximetry, intra-arterial BP measurement)
  • Have external pacing and crash cart available

29

What can we observe on inspection during cardiac assessment?

  • stature (obese?)
  • sternal incision (scars), pacemaker box
  • PMI-5th ICS @ or just medial to left MCL (supine about hte size of quarter)
  • JVD→  Jugular venous pressure- CRNAs do not perform
    • Jugular venous pressure provides an estimate of central venous pressure (CVP). 
      • Jugular vein distention is a sign of increased CVP. 
      • Increased CVP: 
        • right-sided heart failure
        • pulmonary hypertension
        • tricuspid stenosis
        • superior vena cava obstruction. 
  • Edema

30

What can we assess on palpation of chest?

  • PMI (< 2.5cm) – point of maximal impulse (~size of quarter)
    • Cardiac Apex: The tapered inferior tip of the left ventricle → **produces the apical impulse
    • Children/Young adults: PMI easy to visualize/palpate
      • As chest deepens the AP diameter → impulse harder to find
    • Normal Location:
      • Located 5th intercostal space, midclavicular line
      • Supine= the normal PMI about the size of a quarter (~1-2.5 cm).
  • Thrills- vibratory/buzzing sensations caused by underlying turbulent flow
    • Thrills can be palpated by pressing the ball of the hand firmly on the chest.
    • The presence of thrill changes the grading of murmurs